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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D DBA OR FACILITY NAME WHERE TANK IS INSTALLED: )3 7 PE , (C. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# B. MANUFACTURED BY: L41_r C. DATE INSTALLED(MOVDAYNEAR) D. TANK CAPACITY IN GALLONS: O© II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑ 10 PREMIUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OFSUSSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM `I�� SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANKBARE STEEL F-12 STAINLESS STEEL [:] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTok) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED O 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ' �S UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NOx D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION B1 NONE E]95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,9iC. SPILLCONTAINMENT S D(YEAR) OVERFlL P EV NTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES STRIKER PLATE YES DISPENSER CONTAINMENT VES O_ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A Ul SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ACU 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A Y 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ OETECiOR UN 1 .%OCTOCAL E IEM' E]2 WE TIGIRIESS 3 CG ! CTN1 NIFAS1mAL 4 EU_ UK 5 AM PUMP mIIW ❑ MONiGBNO IFMl OE1ECi0R [:] S WR UIIX)m 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ❑ MANUAL INVENTORY VADOZE C TANK WATER E:] ANNUAL TANK RECOCIUATIONMONITORING GAUGING MONITORING TESTING 7NUINTERSTITIAL ❑ 8 SIR 97EA ❑10MOTHLY TANK UNKNOWN 69 OTHER MONITORINGWEEKLY GAUGING NG 5<95 VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(M AVN ) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 3 y SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTW 4 WGNA%RE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW R E C "013 / b 3 a-- COUNTY# JURISDICTION# FACILITY# 0O'T U -113�'J—�' TANK# 00,X— STATE OoL STATE I.D.# PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE YP L THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR IN LLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNGRRGROUNO STORAGE TANK REGULATIONS FORM B (6-95) — 13-- ///�4, FOINQUE07